Gloves-and-Socks Rash With Eosinophilia

A 25-year-old woman presented with a rash of 4days' duration, fever, arthralgia, and headache.The rash, which was localized to the hands, feet,and elbows, was intensely pruritic and was associatedwith swelling and pain in the hands and feet.

The patient had no history of tick exposure, recenttravel, atopic skin diseases, or other significant medicalillness. She denied taking any prescription or over-the-countermedications. Three weeks previously, her sonhad presented with a mild generalized rash and fever.

The patient's physical examination findings includeda temperature of 38.9C (102F), blood pressure of 140/90mm Hg, a pulse rate of 115 beats per minute, and a respirationrate of 18 breaths per minute. There was no peripherallymphadenopathy. The hands and feet wereswollen and erythematous with sharp demarcation at thewrist and ankles (Figures 1 and 2). Multiple purpuricpapules in a glove-and-socks distribution were evident.

The white blood cell (WBC) count was 3200/?L, with20% lymphocytes, 13% monocytes, 50% neutrophils, and17% eosinophils. The absolute eosinophil count was490/?L (normal, 50 to 250/?L). The hemoglobin levelwas 13 g/dL, and the platelet count was 214,000/?L. Theblood chemistry and liver function test results were normal.Serological markers for antinuclear antibody, rheumatoidfactor, hepatitis B and C virus, and HIV were negative.Results from bacterial cultures and a rapid plasma reagin for syphilis also were negative. A parvovirus B19assay yielded a positive result for IgM and a negativeresult for IgG.

A diagnosis of papular-purpuric gloves-and-sockssyndrome (PPGSS) due to parvovirus B19 was made. Thepatient was treated symptomatically with acetaminophen and diphenhydramine. She was discharged on hospitalday 5. At the 3-month outpatient follow-up, the WBCcount was normal and an assay result for parvovirus B19IgG was positive.

PPGSS is a relatively new clinical presentation of parvovirusB19 infection. It was initially described in 1990 asa symmetrical, erythematous, edematous rash of thehands and feet in a gloves-and-socks distribution.¹ Therash is associated with intense pruritus, a characteristicsharp demarcation, and subsequent development of petechiaeand purpura.

An etiological association of PPGSS with parvovirusB19 infection was first suggested by Bagot and Revuz.²Parvovirus B19 is a Parvoviridae first discovered byAustralian virologist Yvonne Cossart in 1971.³ The classicpresentation of parvovirus B19 infection in adultsis fever, rash, or arthropathy; sometimes it is discoveredhematologically. Other infections that may be associatedwith PPGSS are measles⁴; hepatitis B⁵; and thosecaused by Epstein-Barr virus,⁶ human herpesvirus 6,⁷ andcytomegalovirus.⁸

The exact mechanism by which infective agents, especiallyparvovirus B19, cause PPGSS is not known.Histopathological changes include vacuolar interfacedermatitis with necrotic keratinocytes, superficial perivascularlymphocytic infiltrate with rare eosinophils, anddermal erythrocyte extravasations.⁹ Peripheral eosinophiliawas prominent in this case.

PPGSS may be an acute viremic phase of parvovirusB19 infection, unlike erythema infectiosum in children, inwhich the rash occurs after the acute viremia.¹⁰ Early diagnosisof PPGSS is important to limit the exposure ofothers to the virus. It is especially important for personswho may be at risk for severe complications of parvovirusB19 infection, including those with hemolytic disease,pregnant women, and immunosuppressed patients withAIDS, to avoid contact with persons with parvovirus B19infection.

References:

• Harms M, Feldmann R, Saurat JH. Papular-purpuric "gloves and socks" syndrome. J Am Acad Dermatol. 1990;23(pt 1):850-854.

• Bagot M, Revuz J. Papular-purpuric "gloves and socks" syndrome: primary infection with parvovirus B19? J Am Acad Dermatol. 1991;25(pt 1):341-342.

• Cossart YE, Field AM, Cant B, Widdows D. Parvovirus-like particles in human sera. Lancet. 1975;1:72-73.

• Perez-Ferriols A, Martinez-Aparicio A, Aliaga-Boniche A. Papular-purpuric "gloves and socks" caused by measles virus. J Am Acad Dermatol. 1994;30 (pt 1):291-292.

• Guibal F, Buffet P, Mouly F, et al. Papular-purpuric gloves and socks syndrome with hepatitis B infection. Lancet. 1996;347:473.

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• Smith SB, Libow LF, Elston DM, et al. Gloves and socks syndrome: early and late histopathologic features. J Am Acad Dermatol. 2002;47:749-754.

• Smith PT, Landry ML, Carey H, et al. Papular-purpuric gloves and socks syndrome associated with acute parvovirus B19 infection: case report and review. Clin Infect Dis. 1998;27:164-168.